Healthcare Provider Details

I. General information

NPI: 1134068836
Provider Name (Legal Business Name): JACKSON THERAPY COLLECTIVE (FORMERLY TALIA JACKSON PSYCHOTHERAPY SERVICES)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 WAYZATA BLVD
MINNEAPOLIS MN
55405-2123
US

IV. Provider business mailing address

2600 WAYZATA BLVD
MINNEAPOLIS MN
55405-2123
US

V. Phone/Fax

Practice location:
  • Phone: 612-444-1745
  • Fax: 612-484-4557
Mailing address:
  • Phone: 612-444-1745
  • Fax: 612-484-4557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. TALIA AMO JACKSON
Title or Position: LICENSED PSYCHOLOGIST, GROUP OWNER
Credential: PSY.D., LP
Phone: 612-444-1745